Juan Felipe Gutiérrez Sanín was trained as a doctor in Colombia, South America, and now lives in Seattle where he and his wife started a nonprofit, the National Institute for Coordinated Healthcare. The institute trains medical interpreters in hopes of addressing gaps in health care and services that those with limited English proficiency receive in the United States. Sanín spoke with Real Change about the issues facing the medical interpreting profession and the vast opportunities this field presents, especially to those with English as a second language

Can you give us an introduction to the world of medical interpreting, some background and the current state of affairs in this field?There are two aspects to medical interpretation: patient safety and civil rights. First, about patient safety: Studies done in the mid-1980s show that about 70 percent of the information that your physician needs to make the correct diagnosis comes from the initial patient-healthcare-worker interview. That means if your doctor doesn’t speak the same language as you, they’re going to be in a lot of trouble trying to figure out what’s wrong with you because there is no replacement for the interview. Additional studies, done in the early 2000s, show that people who are bilingual, but untrained and unqualified to interpret, make an average of 31 mistakes in a typical 15-minute interview, of which 77 percent, or about 25 mistakes, have negative consequences for the patient. One main problem is that our current national standard for training is only 40 hours [to be qualified as an interpreter] when those same studies show that about 100 hours of training is really needed.

So that illustrates what the patient-safety issue is here. If you look at the national picture of patient safety in the system in general, we’re talking about a system that is already not very safe. Just recently in 2012, we upgraded the number of wrongful or unnecessary deaths as a result of medical errors from 250,000 to 450,000 a year. (According to a 2013 study by the Centers for Medicaid and Medicare, that’s one in seven patients who die or are seriously injured as a result of their care.) This is just the general population. So imagine increasing that by 46 percent and you have a vague idea of how vulnerable people who speak limited English are in the context of the health care system, which is maddeningly complex even for those who speak English natively.

Now, the other aspect of language access in health care has to do with civil rights, specifically Title 6, which states very clearly that no person in the United States — it doesn’t have anything to do with your immigration status or nationality — will on the grounds of their race, color or national origin be excluded from, denied the benefits of or in any way prevented from access to any program or activity receiving any federal financial assistance. I have yet to find one single clinic or doctor’s office that doesn’t take one dime from Medicare or Medicaid. A 1972 lawsuit ruled that nationality necessarily includes language. But until 2000, no one knew how to incorporate this ruling. President Clinton signed Executive Order 1316 in 2000, which essentially obligates all the agencies of the federal government and all recipients of federal financial assistance to come up with what’s called a Language Access Plan; several government departments (like the departments of Justice and Health and Human Services) have templates of access plans on their websites.

A year later, the Office of Minority Health of the Department of Health and Human Services came up with the clas, which stands for culturally and linguistically appropriate services. Of the 15 current standards, five through eight refer specifically to linguistic assistance. So now, if you walk into an emergency room in a hospital, you’re typically going to find a sign written in five or six different languages that says interpreters are available to you at no cost and that health care institutions really need to hire someone who’s qualified to do the job. So first, they need to be tested for proficiency.

This is the really weird thing about the clas standards and regulations pertaining to language access. They don’t tell you what the passing threshold is. They do recommend two scales, the American Council on the Teaching of Foreign Languages (actfl) and the Interagency Language Roundtable (ilr), but again, they don’t define what proficient is.

So it sounds like one of the major issues still is: How do you know what a qualified interpreter is?

Exactly. You go by standards of best practices, and those best practices tell you that if you are hiring someone to interpret for you, they need to test at the ilr level three out of five or at the actfl level of intermediate high, because, traditionally, interpreters don’t translate lengthy documents in writing. Typically, people who are hiring in agencies or hospital administrations don’t test reading and writing, only listening and speaking. Here’s one problem: Ninety percent of interpreters in the state of Washington are independent contractors or they work for a third-party agency, which is sub-contracted by a hospital or clinic to provide these services for them. So because the hospital is outsourcing, they don’t get records. They just believe the agency that hired the person. And so a result, we have a lot of interpreters operating who haven’t been tested or certified at all.

I’m guessing the executive order that Clinton signed did not mandate funding for interpreters, so who’s paying?That’s the other problem. Hospitals and clinics. So it’s an unfunded mandate, and that’s why health care institutions typically reject it like they are escaping from the plague. We’ve threatened health care providers with compliance violations. We’ve been forgetting to mention patient safety (and the risk of malpractice suits) but also, how much money you can save by preventing these errors from happening in the first place. How many days of hospital stays can you cut back for these patients, how many unnecessary visits to the emergency room, etc.? Some states, Washington and New York, that I know of, have started a campaign where now Medicaid is refunding partially — up to 70 percent in some places — for medical interpreters. But it’s pretty much an uphill battle and, of course, it has all the ramifications that we know about, you know, the anti-immigrant crowd saying we need to force everyone to speak English. It’s partly a financial concern, but it’s also a political and racial concern.

Gutiérrez Sanín and his wife Deidre stay healthy by riding off-road bikes. It was Deidre's idea to bring the class to Goodwill.

Photo by Wes Sauer

How do issues of discrimination impact how you train interpreters?Right, I’m glad you asked that question because that’s at the core of the conversation that’s going on around the code of ethics right now. The two national codes of ethics recognize four roles for a medical interpreter to have: conduit, clarifier, cultural navigator and advocate. The advocate basically levels the playing field where there is an imbalance of power and speaks up on behalf of the patient when there is an instance of mistreatment or abuse or to report things that are wrong. So these four roles exist in the national code of ethics. Our state code of ethics recognizes the roles of the conduit and the clarifier and stops there, which is being interpreted to mean that advocacy is forbidden. That makes sense if you’re working in a court and you’re interpreting for someone who already has an attorney. But if you walk into a doctor’s office, it’s a different story.

My nonprofit created training for what we call patient-care advocates, and these are people who are known by other names like community health workers or personal health coaches or patient navigators. These are people who are going to be a coach, an educator; [they] are going to tell you as a recent immigrant to the country how the crazy healthcare system works, and how to get an appointment with your primary doctor; how to follow up with your pharmacy; where to get your medicines, etc.

So it’s almost like a case-worker model?It’s basically taken after the case-management model but goes beyond it by adding a system-navigation piece. So, in addition to what I mentioned, helping them with the basic things like housing and reliable transportation — both are issues for people who are chronically ill of any ethnicity. Basically, patient advocates are going to work as part of a team — a doctor, a nurse, typically a social worker or case manager or both, and a community health worker — called a patient-centered medical home. They coordinate care that can range from making a simple phone call to reminding Ms. Gonzalez that she has an appointment to draw her blood to going to her home and helping her figure out how to use her cpap machine.

Because my nonprofit is working with local communities and hospitals, that gives us an opportunity to recruit people from these immigrant and low-income neighborhoods and offer them a career path and help them climb out of poverty. At the same time, we encourage people who are coming from the community to stay there, work for the local healthcare organizations and pull the community up. So it’s kind of like the reversal of the typical vicious cycle [caused by limited English proficiency] that we’re trying to create.

And instead of language being this barrier that people experience, becoming an interpreter can be used as a doorway and also to strengthen communities?Yeah, you have to take a holistic perspective in order to actually fix anything. I hear this all the time, I was working with a vocational school a couple of quarters ago where some of the people, they have a 60-hour interpreting class and they were trying to connect that with my certificate program. I was talking to them about these opportunities, and one of the girls in the classroom said, “Oh, so my ability to speak a second language is actually a good thing? I can do something with it?” Yes, you can do a lot of good with second languages. And you can actually also make decent money and have a decent life as a result.

This might be sort of obvious, but who is most interested in signing up?Everyone. I get a lot of awesome people. Well, I guess that has to do with being at the right place. The neighborhoods, the zip codes around Highline College, are about twice as diverse as the rest of Seattle, and there are probably twice as many people who are low-income. And there are probably three times as many people who are uninsured within the neighborhood. So, at the same time, [they] are people who are very hungry for opportunities. It was actually my wife, Deidre, who had a brilliant idea last summer to talk to a manager at Goodwill about speaking at their training center. That exploded, basically; for the next quarter, two-thirds of my classroom came from Burien Goodwill and that became a stable trend. So now every quarter, I go and talk to the students at the Goodwill. They sign up for my class, I connect them with internships that I kind of establish with corporate partners so after they complete each certificate program, there’s an internship opportunity and the potential for a job at the end of that. I don’t have to be on top of them, reminding them to do their work. They come up with awesome questions. They’re so engaged. They get me in trouble sometimes, because they question what I tell them in the classroom. I love working with them because I can see the fire in their eyes.

So that really makes my day every time that I get to work with that group. We are expanding and teaching some classes at a satellite center in White Center with a number of refugees. It’s a really diverse group, I have some 14 people from 10 different countries and only two of them are American women who speak Spanish. The rest of them speak something else.

So this is the first time that I don’t have a majority of Spanish speakers in the class.

So if someone reads this and says, ‘I really want to do that … I want to be a medical interpreter,’ what do they need?At least a high school diploma or GED, you have to be over 18 or get permission from your parents, and basic bilingual proficiency, so if you can carry a conversation between English and a second language, you’re good. Something I didn’t mention is funding, we have these three streams of funding coming into the program — if you qualify for food assistance, you qualify for federal aid; WorkSource and women’s programs. So chances are if you are low-income and you want a second career, you’re probably not going to have to pay for the class. These are all accredited classes — Highline is now a four-year college — and the program is part-time, but you still get homework!